Thursday, January 6, 2011

Consequences of judicious antibiotic use

A physician reader of AFP submitted the following post.

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I appreciated the article in the December 1, 2010 issue, "Diagnosis and Treatment of Acute Bronchitis," especially its discussion of the preponderance of viral versus bacterial infections and the need to be more judicious in our use of antibiotics for bronchitis. I strive to practice evidence-based medicine and spend a lot of time explaining my decision to not prescribe antibiotics for viral conditions. However, this practice comes at a cost.

My colleagues and I have a busy group family practice in Des Moines, Iowa, and we take turns staffing the walk-in clinic. Recently, a father brought in his teenage son with an obvious viral condition that had lasted for three weeks. After a thorough history and physical exam, I told them that it appeared to be a viral syndrome, but I would go ahead and do a complete blood count with differential and rapid Strep screen just to be certain.

When the laboratory technician entered the room, the father told her that they didn’t need the lab work and she should tell the doctor to just give them some antibiotics. The lab tech appropriately told the patient that the doctor had ordered the tests to see if he needed them or not, and they allowed the specimens to be taken. The results showed a negative Strep screen and a low white blood cell count with a right shift in the differential. I spent some time going over the lab results and explaining why it was unnecessary to prescribe an antibiotic for a viral illness, and wrote a prescription for Robitussin with codeine for symptomatic relief. The patient and his father then stormed out of the exam room and through a crowded waiting room, with the father yelling, “This (expletive) clinic sucks!”

A little while later, I received the following message from the patient's mother on my office voice mail: “My son was just seen in the walk-in clinic. He has been sick for three weeks and we waited for three hours to get in, but the 'care' he got from you was ridiculous. Just take some Robitussin? This is exactly why we have stopped going to your clinic regularly, because the doctors there are no help whatsoever. I can tell you I am going to give you every bad review I can on the Internet and everybody I know, I will tell.”

We receive similar complaints fairly commonly. Although they will not dissuade me from "doing the right thing" regarding antibiotic prescriptions, I wonder how many other clinicians will continue to suffer the slings and arrows of a demanding public when it is a lot easier, less time consuming, and certainly less stressful to just give patients what they want. I would, however, encourage all of my primary care colleagues to stick to our guns in educating the public about the appropriate use of antibiotics, despite the occasional assaults on our professional integrity.

Steve R. Eckstat, DO
Medical Director
Mercy West Medical Clinic
Des Moines, Iowa

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